The MAGAZINE of the Johns Hopkins Bloomberg School of Public HealthSummer 2009 | www.jhsph.edu

Mending Wounded Minds

In developing countries, three-quarters of people with mental disorders receive no treatment. How do you deliver inexpensive, effective, science-based care to them? A team of mental health researchers has a few ideas.

Story by Jackie Powder

The Kurdish people of northern Iraq have endured the worst that man can do to man. Operation Anfal, Saddam Hussein’s campaign of genocide against the Kurds, claimed 180,000 victims—5,000 killed in the poison gas attacks of 1988—and destroyed thousands of villages, forcing residents from their homes to refugee camps on the Turkish border. During this wave of terror, males were routinely detained, taken to military facilities, interrogated, tortured and often executed. In some cases, their families were forced to watch the killings in a public place, applaud and then pay for the bullets used in firing squad assassinations.

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More than 20 years have passed, and Saddam Hussein is gone. What remains is a damaged population—torture survivors, their relatives and the families of the dead—that continues to live with crippling psychological pain.

“It’s very common to find families having one or two members who have been jailed or tortured,” says Ahmed M. Amin, MD, medical director of a trauma recovery and training center in Sulaimaniya. “For example, if I am not jailed, my brother was jailed; if not my brother, my sister or my cousins.

“We know that they are in grave need of mental health support services,” Ahmed says. “They have a great burden on their shoulders, and they are suffering on a daily basis.”

To ease the debilitating mental pain that frequently destroys family relationships and impedes day-to-day functioning, the Bloomberg School’s Applied Mental Health Research (AMHR) group is working on a project to help torture victims in Kurdistan. The effort is led by Paul Bolton, MBBS, MPH, an associate scientist in International Health, and is supported by USAID’s Victims of Torture Fund.

The AMHR group is dedicated to implementing and testing evidence-based mental health services in developing countries where care for the mentally ill is frequently non-existent or ineffective. Bolton and colleagues Judith Bass, PhD, MPH, and Laura Murray, PhD, assistant professors in Mental Health and International Health, respectively, comprise the core of AMHR, which they founded at Boston University’s School of Public Health in 2004.

During Saddam Hussein’s genocide against the Kurds, families were brought to prisons to witness the torture of loved ones. The girls might be raped. Then the families were sent home. “We’ve heard many stories, and these are the worst I’ve ever heard,” says Paul Bolton.

The group has worked with street kids in Georgia, Albania and Mexico, sexually abused children in Zambia, Indonesian villagers caught for two decades in the crossfire of warring political factions, and with affected populations in Uganda, Cambodia and Haiti.

AMHR doesn’t provide treatment services directly, but rather fills a void in how these services are planned, executed, and provided. The group uses data collection methods in collaboration with service providers to identify major mental health problems, assist in the selection and design of mental health interventions to address these problems, and set up monitoring and evaluation methods to assess their impact. It is then up to the service providers—typically NGOs or ministries of health—to deliver the selected science-based mental health care.

“I would say that international mental health at the moment is certainly not a science-based or evidence-based field, leaving people free to do whatever they think is a good idea at the time,” says Bolton, who originally trained as a family physician in Australia. In the late 1980s, he focused on tropical medicine, treating malaria, tuberculosis, parasitic infections and diarrheal diseases among refugees in camps along the Thai/Cambodian border. In 1996, he joined the Child Survival Support Program at Johns Hopkins.

“I saw people with mental illness,” Bolton says, “but we had nothing to offer them.” He adds, “The contrast between the rigorous evidence that underlies physical health programs, and the poor basis for the few mental health services that were being provided was really marked.”

While mental health issues in the developing world have not drawn wide attention, they disrupt the lives of millions, says Bolton. The effects of mental illness can ripple wide, far beyond an individual’s personal pain and dysfunction to economic hardship and the disintegration of families.